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6. The implant Trade name: Nexplanon ® Up to 3 years of protection 60 mcg etonorgestrel/day Implanted in upper arm 4cm flexible, plastic rod Pregnancy rate 0.1/ 100 women/year Mechanism of action Suppresses ovulation in most (if not all) users Changes cervical mucus Thins lining of uterus

7. Bleeding PatternsDefinitions %* InfrequentLess than three bleeding and/or spotting episodes in 90 days (excluding amenorrhea) 33.6 AmenorrheaNo bleeding and/or spotting in 90 days 22.2 ProlongedAny bleeding and/or spotting episode lasting more than 14 days in 90 days 17.7 FrequentMore than 5 bleeding and/or spotting episodes in 90 days 6.7 * % = Percentage of 90-day intervals with this pattern Bleeding Patterns During the First Two Years with the Implant

8. Breast cancer Cirrhosis/ liver tumors/ active liver disease Unexplained vaginal bleeding The implant should not be used in patients with…

9. Insert any time in cycle as long as pregnancy can be ruled out Procedure is simple and quick Clinician injects numbing medicine into arm Slides rod under skin between bicep and tricep The implant insertion

13. Hormonal IUDs Trade name: Mirena® or Skyla® Up to 5 years of protection (Mirena) or 3 years (Skyla) Releases 20 mcg LNG/day (Mirena) or 14 mcg LNG/Day (Skyla) Pregnancy rate 0.2/100 women/year No long-term effect on fertility Mechanism of action: Thickens cervical mucus Suppresses endometrium Does not reliably suppress ovulation

14. Improvement of heavy periods Improvement of painful periods No periods Treatment of fibroids and endometriosis Hormonal IUD: Non-Contraceptive Benefits

15. Bleeding irregularities No period 20% at 1 year 50% at 5 years Expulsion rate 5% over 5 years Perforation Occurs in approximately 1 out of 1000 insertions Hormonal IUD: Potential side-effects and concerns

16. Trade name ParaGard ® Up to 10 years of protection Pregnancy rate 0.8/ 100 women/year No long-term effect on fertility Mechanism of action: Increases copper ions, enzymes, prostaglandins, and white blood cells in uterine and tubal fluids Impairs sperm function and prevents fertilization Non-hormonal IUD

17. No systemic side effects Cramping/heavy bleeding most common in first 3 months manage with NSAIDs Expulsion rate: 2-10% Perforation Occurs in approximately 1 out of 1000 insertions Non-hormonal IUD: Potential side-effects and concerns

18. Known/suspected pregnancy Unexplained vaginal bleeding Active cervicitis Pelvic inflammatory disease (PID) in past 3 months Postpartum or post- abortal infection in past 3 months Uterine abnormalities that interfere with insertion Genital tract cancer The copper IUD should not be used in patients with…

19. IUD insertion can be crampy Usually lasts <5 minutes Patient can take ibuprofen beforehand to help Insert any time in cycle as long as pregnancy can be ruled out Same-day insertion the standard No benefit to waiting until patient has menses Making patient return for a second visit creates unnecessary barriers Insertion of the IUD

22. Improvement of heavy periods Improvement of painful periods Improvement of endometriosis symptoms Minimal drug interactions The birth control shot: Non-Contraceptive Benefits

23. 40 to 50% discontinuation at 1 year Irregular bleeding No periods 17% at one year of use 80% at 5 years of use Weight gain Decrease in bone mineral density (BMD) Reversible after woman stops using method Delayed return to fertility (7- 12 months) The birth control shot: Potential side-effects and concerns

24. Breast cancer Cirrhosis/ liver tumors/ active liver disease Unexplained vaginal bleeding The shot should not be used in patients with…

25. Preferred method: “Quick Start” start immediately and use backup x 7 days Switch from another method→ start immediately If using Quick Start, woman should have a repeat pregnancy test in 3 weeks The birth control shot: when to start

26. 3 methods: Oral contraceptive pill Contraceptive patch Vaginal ring Contain estrogen and progestin Pregnancy rate 9/100 women/year Mechanism of action Thicken cervical mucus Suppress ovulation Combined hormonal contraceptives

27. Menstrual benefits: shorter, more regular period lighter flow and decreased anemia less painful periods decreased number of periods per year Treatment of endometriosis Improvement of acne Prevention of functional ovarian cysts Decreased risk of ovarian and endometrial cancers Pill Patch and Ring: Non-contraceptive benefits

28. Discontinuation: 11% in 1st month, up to 50% 1st year Some studies show higher discontinuation rates for patch, lower for ring Breakthrough bleeding Nausea Breast tenderness Headaches Mood changes/decreased sex drive High blood pressure Weight gain Pill Patch and Ring: Side-effects and concerns

29. Smoker ≥35 years Personal history of venous or arterial thrombotic event (DVT/PE-blood clot, MI-heart attack, CVA- stroke) Complicated diabetes Migraine with aura Any migraine headache if ≥35 years Hypertension Coronary artery disease Active liver disease Breast Cancer These methods should not be used in women who…

30. Preferred method: “QuickStart” start immediately and use backup x 7 days may improve continuation Day 1 Start & Sunday start may put woman at risk for unintended pregnancy Switch from another method Start immediately and backup method is not necessary Pill Patch and Ring: when to start

32. Estrogen and progestin-containing pill that a woman takes every day Typical use 21 days active pill, 7 days no/inactive pill 24 day regimens 24 days active pill, 4 days no/inactive pill Extended regimens and continuous use Take pill at same time every day for maximum effectiveness Combined Oral Contraceptives

34. The Patch Trade name: Ortho Evra ® Patch Estrogen and progestin-containing adhesive that a woman wears on her upper arm, lower abdomen, buttocks or upper torso (excluding breasts) Change patch 1 x week for 3 weeks, then patch-free for 1 week Side effects: detachment 2% site reaction 20% Less effective in obese women >198lbs

37. The Ring Trade name: NuvaRing ® Estrogen and progestin- containing flexible plastic ring a woman inserts herself into her vagina 21 days ring in, 7 days ring out and then insert a new ring Extended regimens possible Effective in 24 hours Can remove for up to 3 hours in a 24-hour time period

38. Depo-medroxyprogesterone acetate (DMPA), or Depo- Provera Injected once every 12 weeks intramuscular injection: 150 mg subcutaneous injection: 104 mg Pregnancy rate 4/100 women/year Mechanism of action Primary mechanism: inhibits ovulation Thickens cervical mucus Thins lining of the uterus The birth control shot

39. Improvement of heavy periods Improvement of painful periods Improvement of endometriosis symptoms Minimal drug interactions The birth control shot: Non-Contraceptive Benefits

40. Progestin-only pills Also known as the “mini-pill” or POPs May be less effective than birth control pill need for strict compliance “27-hour rule” No “pill-free interval” – active pill taken every day Commonly used in breastfeeding women Side effects irregular bleeding or no period at all

46. Offer protection against STIs Require motivated user: must use at every act of intercourse Mechanism of action Do not contain hormones Physical barrier blocks sperm from entering the uterus Barrier methods

48. Emergency contraception 3 types of emergency contraception -Oral levonorgestrel (Plan B ®, Next Choice ® ) – Available over-the-counter for all ages -Oral ulipristal (ellaOne ® ) – Progesterone receptor blocker -Copper IUD (ParaGard ® ) – Most effective form of EC Use after unprotected intercourse or underprotected intercourse Up to 120 hours after Sooner is better

49. Prevents unintended pregnancy will not interrupt an established pregnancy Prevents or delays ovulation Ineffective after implantation Emergency contraception: Mechanism of action

50. No reports of serious complications/death Side effects with oral LNG: nausea 25% vomiting 10% irregular bleeding Repeated use appears safe Opportunity for contraceptive counseling No scheduled follow-up is required No evidence of birth defects Emergency contraception: safety